Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 2

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6.
(a) Where does the claimant live?
Alone
In my home (Go to (b).)
In a public institution (Go to (c).)
With a relative (Go to (b).)
In a private institution (Go to (c).)
With someone else (Go to (b).)
In a nursing home (Go to (c).)
In a board and care facility (Go to (b).)
In the institution I represent (Go to (c).)
(b) Enter the names and relationships of any other people who live with the claimant.
NAME
RELATIONSHIP
(c) Enter the claimant's residence and mailing addresses (if different from yours).
Residence:
Mailing:
Telephone Number:
(d) Do you expect the claimant's living arrangements to change in the next year?
YES
NO
If YES, explain what changes are expected and when they will occur. (Use Remarks if you need more
space.)
7.
If you are applying on behalf of minor child(ren) and you are not the parent,
Does the child(ren) have a living natural or adoptive parent?
YES
NO
If YES, enter: (a) Name of parent
(b) Address of parent
(c) Telephone number
(d) Does the parent show interest in the child?
YES
NO
Please explain.
8.
List the names and relationship of any (other) relatives or close friends who have provided support and/or show active interest
with the claimant. Describe the type and amount of support and/or how interest is displayed.
NAME
ADDRESS/PHONE NO.
RELATIONSHIP
DESCRIBE
9.
Check the block that describes your relationship to the claimant.
(a)
Official of bank, agency or institution with responsibility for the person. Enter below which you represent:
Bank
Social Agency
Public Official
Institution:
Federal
State/Local
Private non-profit
Private proprietary institution. Is the institution licensed under State law?
YES
NO
IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 4.
(b)
Parent
(c)
Spouse
(d)
Other Relative - Specify
(e)
Legal Representative
(f)
Board and Care Home Operator
(g)
Other Individual - Specify
IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 2

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